Scientific Abstract Presentations: Hand Session 3 Friday, October 10 Fri, Oct 10 10:30 a.m.-12:30 p.m. CDT

Introduction Disability rates following burn trauma vary significantly based on burn severity, total body surface area (TBSA) affected, and the presence of complications. Specifically, hand burns, due to their impact on functional tasks and quality of life, are associated with considerable long-term disability. Previous studies have demonstrated that hand burns, particularly when bilateral or requiring grafts, result in significant impairment, including delayed return-to-work (RTW) and persistent functional limitations. This study aims to examine the influence of socioeconomic factors, including the Area Deprivation Index (ADI), on the likelihood of filing for disability after a hand burn injury. By identifying key predictors of disability, the study seeks to highlight potential areas for intervention to improve outcomes for hand burn patients. Methods A retrospective analysis was performed to examine the demographics, insurance status, Area Deprivation Index (ADI), employment, and disability status of patients treated for hand burns. The ADI quantifies socioeconomic factors on a scale from 0 to 10, with 0 representing the least disadvantaged and 10 indicating the greatest disadvantage. The study included all patients who presented with hand burns between April 2009 and December 2022. Results A total of 165 patients were treated for hand burns in our cohort. The majority of patients were publicly insured (n=113, 68.3%), with a median Area Deprivation Index (ADI) state decile of 7, indicating a high degree of socioeconomic disadvantage. Among the 91 patients employed prior to their injury (55.2%), 56% returned to work after their injury. Following their hand burn injury, 35% (n=58) of patients filed for disability. Severe burn injuries, defined as a Total Body Surface Area (TBSA) greater than 20%, were significantly associated with disability claims (χ² = 6.76, p < 0.01). However, even patients with more localized hand burns exhibited high rates of disability, with 29% filing for disability. A logistic regression model was used to assess factors influencing disability, incorporating variables such as ADI state decile, TBSA, Length of Stay (LOS), and preexisting comorbidities. The model revealed that each 1-point increase in ADI decile was associated with a 17% increase in the odds of filing for disability (p = 0.037). Additionally, TBSA and comorbidities had significant effects on disability status (p = 0.014 and p = 0.035, respectively). Conclusion Hand burns, whether occurring in isolation or as part of larger burn trauma, are associated with high rates of disability. This study highlights socioeconomic factors, particularly the Area Deprivation Index (ADI), as significant predictors of filing for disability following a hand burn injury. These findings suggest that addressing socioeconomic disparities may offer an important avenue for targeted interventions to reduce disability rates and improve outcomes for patients after hand burn trauma.

Purpose: Raynaud's phenomenon can have debilitating effects on daily function and quality of life. Botulinum toxin A (BoNTA) injection has become an increasingly popular treatment for vasospastic digits in Raynaud's, but its use remains controversial and there are no clear clinical guidelines. This study aims to review the existing literature on BoNTA for Raynaud's and assess its impact on functional outcomes.

Methods: A systematic review was conducted using PubMed and Embase. Search terms included "Botulinum Toxin A," "Botox," "Raynaud's Phenomenon," "Raynaud's," and "vasospasm." Randomized controlled trials, as well as prospective and retrospective studies, were included in the analysis. Studies not written in English or lacking full-text availability were excluded. Additionally, pediatric and cadaveric studies, as well as case reports, were not included.

Results: The initial search yielded 218 articles, and 48 duplicates removed. After title and abstract review with two independent reviewers, 115 articles were further excluded resulting in 66 articles to undergo full text review. In total, 23 studies were included in the final analysis. The studies were heterogeneous in nature, with no uniformity in injection site, BoNTA dosage per hand or site, or injection frequency. BoNTA doses ranged from 10 to 500 units per hand. Five injection sites were described: intra-/interdigital, palmar, dorsal, MCP level, and proximal wrist, with intra-/interdigital being the most common. Fifteen studies (65.2%) examined BoNTA's role in ulcer healing, and 12 (52.2%) reported full or partial improvement. The outcomes varied, including Visual Analog Score (VAS) for Pain, Quick-DASH (Disabilities of the Arm, Shoulder, and Hand (DASH), digital pulp temperature, custom-specific scales, or no specific outcome descriptions. VAS was the most reported outcome (n=8, 34.7%). Using a random effects model, we found a significant improvement in pain according to VAS after BoNTA injection (p<0.001)

Conclusion: BoNTA may substantially reduce pain associated with Raynaud's phenomenon. However, there are currently no clinical guidelines for its use in these patients, leading to variations in the amount injected and the injection locations. Future initiatives will focus on reporting our institutional data and sharing anecdotal experiences with incorporating BoNTA for Raynaud's into clinical practice.

Purpose: Carpal tunnel release (CTR) is among the most common hand procedures performed by plastic surgeons. While Enhanced Recovery After Surgery (ERAS) protocols emphasize minimizing opioid use, comparative data on intraoperative opioid requirements between open and endoscopic CTR remain limited. We hypothesized that open CTR would require less intraoperative fentanyl than endoscopic CTR due to increased tissue manipulation with the latter's dilator-based technique. Secondary aims included evaluating procedural efficiency, resource utilization, and the effect of surgeon-specific practice patterns.

Methods: We conducted a retrospective review of 296 CTR cases (148 open [CPT 64721] and 148 endoscopic [CPT 29848]) performed by five fellowship-trained hand surgeons at a single institution from 2020 to 2023. Multivariate regression analysis was performed to examine primary outcomes (total and weight-adjusted fentanyl dose) while controlling for age, gender, ASA class, and surgeon. Secondary outcomes included surgical and anesthesia time, as well as cost implications. To ensure uniformity, only isolated CTR cases or those with concurrent trigger finger release were included.

Results: Contrary to our hypothesis, no significant difference was found in fentanyl requirements between open and endoscopic techniques after multivariate adjustment (59.0±27.3mcg vs. 63.1±26.8mcg, p=0.20; weight-adjusted: 0.72±0.34mcg/kg vs. 0.74±0.33mcg/kg, p=0.54). However, endoscopic CTR was significantly more time-efficient, with shorter surgical (14.7±4.1min vs. 28.1±7.2min, p<0.0001) and anesthesia times (54.2±8.2min vs. 61.6±9.4min, p<0.0001). When analyzed by surgeon, variation in fentanyl dosing within each technique (42.8% variation among open CTR surgeons, 19.6% among endoscopic CTR surgeons) exceeded the variation between techniques (3.3%). In our multivariate model, individual surgeon emerged as a more significant predictor of fentanyl requirements than surgical technique (p<0.001). ASA classification had no significant impact on anesthesia time or opioid requirements.

Conclusions: Despite theoretical concerns about increased pain from dilator-based tissue manipulation in endoscopic CTR, our study demonstrates no significant difference in intraoperative fentanyl requirements between techniques. While endoscopic CTR offers substantial time savings, its higher cost must be considered, with a recent analysis of 8,717 patients showing that open procedures had a 44.3% decrease in total charges compared to endoscopic procedures (1). Most notably, surgeon-specific practice patterns had a greater impact on intraoperative fentanyl use than surgical approach, suggesting that standardizing anesthesia protocols across surgeons-rather than focusing solely on technique-may be more effective in optimizing opioid use in ambulatory hand surgery. These findings provide valuable guidance for refining ERAS protocols in CTR.

References: 1. Brodeur PG, Raducha JE, Patel DD, Cruz AI Jr, Gil JA. Cost Drivers in Carpal Tunnel Release Surgery: An Analysis of 8,717 Patients in New York State. J Hand Surg Am. 2022;47(3):258-265.e1. doi:10.1016/j.jhsa.2021.10.022

Hypothesis / Purpose We hypothesize that performing endoscopic carpal tunnel release (ECTR) under wide-awake local anesthesia with no tourniquet (WALANT) in an office-based setting will reduce overall costs and maximize efficiency compared to the same procedure performed in a surgery center setting (1,2).

Methods This retrospective cost analysis compared the financial implications of ECTR with WALANT in an in-office procedure room (n=25) versus a surgery center (n=25). Data was collected from institutional billing records, Medicare Part B reimbursement rates, patient out of pocket expenses, and facility operational expenses from January 2022 to January 2025. Costs were analyzed from the perspectives of the patient, surgeon, facility, and insurer. Inclusion criteria included patients with Medicare Part B insurance undergoing an isolated ECTR procedure.

Results The facility fee for ECTR performed at a surgery center was $3,600.00, with $2,880.00 covered by insurance and $720.00 paid by the patient. The surgeon fee was $542.30, with $433.84 reimbursed by insurance and $108.46 billed to the patient. The total amount billed to insurance for a surgery center procedure was $3,313.84, while the total out-of-pocket cost for the patient was $828.46. For ECTR performed in an office-based setting, the surgeon fee remained $542.30, with $433.84 covered by insurance and $108.46 paid by the patient. The cost of surgical supplies for the in-office procedure was $288.86, and no facility fee was charged. The total amount billed to insurance for the in-office procedure was $542.30, while the total out-of-pocket cost for the patient was $108.46. From the surgeon's perspective, profitability was higher when the procedure was performed at the surgery center, primarily due to the costs associated with surgical supplies, including the endoscopic carpal tunnel release device. However, by optimizing efficiency in the office setting, surgeons can achieve greater overall profitability by performing two to three times more surgeries within the same timeframe.

Conclusion Performing ECTR with WALANT in an office-based setting significantly reduces costs for patients and insurers without compromising outcomes. Surgery center costs are inflated by facility fees and recovery expenses, whereas in-office procedures optimize efficiency. These findings support a shift toward in-office procedures as a cost-effective alternative, aligning with value-based care initiatives.

References

1. Ekhtiari S, Phillips M, Dhillon D, Shahabinezhad A, Bhandari M. A cost-utility analysis of carpal tunnel release with open, endoscopic, and ultrasound guidance techniques from a societal perspective. J Hand Surg Glob Online. 2024;6:659-664. doi:10.1016/j.jhsg.2024.06.006

2. Hubbard ZS, Law TY, Rosas S, Jernigan SC, Chim H. Economic benefit of carpal tunnel release in the Medicare patient population. Neurosurg Focus. 2018;44(5):E16. doi:10.3171/2018.1.FOCUS17802

Background Alcohol and drug use contribute significantly to the morbidity and mortality of traumatic injuries. The purpose of this study is to explore the impacts on drugs/alcohol on the epidemiology of traumatic hand injuries in the U.S.

Methods The National Electronic Injury and Surveillance System (NEISS) database was queried from 2019-2022 to identify patients admitted to the emergency department (ED) with reported hand injuries. Patients with alcohol/drug involvement at the time of their injury were isolated as a separate comparison group. Variables including sex, race, products involved in injury, and ED disposition were assessed between the two patient cohorts utilizing two-proportion z-tests.

Results In total 202,979 patients with traumatic hand injuries were identified with 3,013 cases involving drugs and/or alcohol. Laceration injuries occurred at a significantly higher frequency in cases involving drugs/alcohol than those that did not (43.4% vs. 35.2%, p< 0.001) followed by contusions (10.4% vs. 8.7%, p= 0.001) and avulsions (3.4% vs. 2.2%, p< 0.001). The most common cause of hand injury in both populations was knives, with cases involving drug/alcohol injuries incurring at a higher frequency than injuries with no drug/alcohol involvement (11.7 % vs. 10.1%, p=0.007). The overall odds ratio of hospital admission following hand injury for cases that involved alcohol/drugs (relative to those that did not) was 5.2 (95% CI: 4.6-5.9, p<0.001)

Conclusion The likelihood of hospitalization following hand injury is over five-fold greater under the influence of drugs/alcohol, with a significantly greater frequency of specific injury types/etiologies. Ultimately, these epidemiological findings can be leveraged to provide emergency department personnel, and hand surgeons qualitative context for the most frequent presentations of hand injuries.

Background: Digital amputation is required to address trauma, infection, or necrosis of the digit when salvage options are not available. The goals of the amputation are to remove diseased or injured tissue while preserving as much function and sensation as possible. Digital amputation can have profound impact on the patient, and the need for revisionary procedures may extend the length of recovery and associated psychologic burden. Previous studies have found revisionary procedures to be as high as 15-34%. Diabetes, peripheral vascular disease, and end-stage renal disease are risk factors for subsequent surgery. The purpose of this study was to identify additional factors associated with reoperation or revision in digit amputation, and to compare the risk of reoperation between traumatic and atraumatic surgical indications.

Methods: A retrospective chart review of all patients undergoing operative digital amputation at a multi-institutional healthcare system 01/01/2007 to 12/31/2021 was performed. Indication for digital amputation, comorbidities, surgical details, and complications were collected for each patient. Statistical analysis consisted of X2 and Fisher exact tests for categorical variables and T-tests for continuous variables.

Results: 262 patients met all inclusion criteria. 187 (71.40%) patients were male and 137 (52.29%) were Black, with a mean age of 58.2. 95 (36.25%) patients underwent amputation for a traumatic etiology while 167 (63.75%) underwent amputation for atraumatic cause. The reoperation rate was 17.2%, with the most common reasons being wound healing complication, suboptimal healing, further ischemia/gangrene, and infection. Atraumatic reason for initial amputation was significantly associated with increased complications (7.81, p=0.0052). BMI>30 (LR 2.06, p=0.15), history of substance use (LR 2.969, p=0.0849), and atraumatic reason for amputation (LR 2.20, p=0.137) trended toward an increased need for reoperation, although this did not achieve statistical significance. Age <65 (LR 10.02, p=0.0065), autoimmune disease (LR 6.03, p=0.014), and vascular disease (LR 6.03, p=0.014) were found to be significantly associated with subsequent reoperation. Additionally, history of chronic pain (LR 4.819, p=0.0282) and initial operation performed by PRS as opposed to orthopedic, surgical oncology, or vascular services, were significantly associated with increased likelihood of reoperation (LR 9.792, p=0.0441).

Conclusion: Digital amputations are common procedures that impact function and quality of life. Additional surgeries or procedures may be required after the initial amputation to allow for tissue healing or improve quality of life. Younger age, autoimmune disease, and vascular disease may predict the need for multiple procedures. Surgeons should use this information to guide preoperative counseling.

Purpose: Kienböck's disease is a rare condition that commonly affects individuals between 20-40 years of age. There is a paucity of published data describing the natural history of pediatric Kienböck's disease (patients under the age of 18). The current recommendation is to treat pediatric Kienböck's disease nonoperatively with limited data on its surgical management. We strived to assess radiographic and clinical outcomes of pediatric Kienböck's disease treated operatively versus nonoperatively.

Methods: A retrospective review was performed at a single large, tertiary-care referral center and regional level 1 pediatric trauma hospital. Patients under 20 years of age diagnosed with Kienböck's disease between January 2014 to July 2024 were included. Sixteen patients with Kienböck's disease were identified (mean age 15.5 +/- 2.2 years). 5 underwent nonoperative management (casting), and 11 underwent surgery. Of the surgical cases, 10 had lunate offloading: 4 radial shortenings, 5 scaphocapitate pinnings, 1 radioscaphocapitate and radiolunate pinning. 8 surgical patients additionally received vascularized bone grafts. 1 patient underwent proximal row carpectomy.

Results: Nonoperative cohort: 3 Lichtman stage 1, 1 stage II and 1 stage IIIB. Average casting time was 2.2 months, with average follow-up of 10.5 months. Mean change in ulnar variance (ΔUV) was 0 (p=1.00), in radioscaphoid (ΔRS) angle was -8.9 (p=0.42), and in capitate radius distance (ΔCR index) was -0.5 (p=0.10).

Operative cohort: 7 Lichtman stage IIIA, 2 stage IIIB and 1 stage IIIC with average follow-up of 13.2 months. Mean change in ulnar variance (ΔUV) was 0 (p=0.15), in radioscaphoid (ΔRS) angle was -8.9 (p=0.15), and in capitate radius distance (ΔCR index) was -0.5 (p=0.05). Patients who underwent lunate offloading had ΔUV of +0.4, ΔRS angle of +1.4, and ΔCR index of +0.2. Patients who underwent lunate offloading with vascularized bone graft had ΔUV of +0.7, ΔRS angle of +6.2, and ΔCR index of +0.6. When comparing lunate offloading procedures to vascularized bone grafts, there was no signficant difference in ΔUV (p=1.00), ΔRSA (p=0.79), ΔCR Index (p=0.69)

Conclusion This study presents a small series of patients who have failed conservative management and benefitted from operative intervention, suggesting that there is a role for surgery in this rare subgroup of a rare disease. Both radiographic and clinical improvement remains mixed in both the nonoperative and operative cohorts.

Background: Antithrombotic medications, including anticoagulants (AC) and antiplatelets (AP), are commonly prescribed to prevent thromboembolic events in patients with cardiovascular or hypercoagulable conditions. The current US and European guidelines suggest stopping AC/AP use 3-5 days prior for both cardiac and non-cardiac surgeries, but recently, it has been shown that the continuation of anticoagulation in select operations, such as urologic surgery and endoscopy, does not increase bleeding events and may be favorable in continuing to prevent thrombotic events (1-3). The study of perioperative AC/AP continuation remains limited in elective hand and wrist surgeries.

Objective: This systematic review aims to synthesize the most recent literature on the continuation of AC/AP therapy in hand and wrist surgery. Prior reviews have proposed there is not a clinically significant increase in bleeding risks when these medications are maintained perioperatively.

Methods: A comprehensive search of PubMed and Embase databases based on PRISMA guidelines was performed, yielding 149 results. After full text screening, 12 relevant articles were included in this review.

Results: All 12 articles evaluated, including prospective and retrospective cohort studies and a case report, suggest that continuing AC/AP therapy during elective hand surgery provides a lower risk of bleeding complications compared to the possibility of thromboembolism should the medications be uninterrupted. Complications of perioperative anticoagulation were commonly subcutaneous hematomas that were managed non-surgically and occasionally major hematomas that required reoperation. 6 out of the 10 studies that collected hematoma as an endpoint recorded episodes of bleeding. 3 articles each reported one patient in the AC/AP cohort with postoperative hematomas that required reoperation or revision surgery. One case study reported PE after a patient paused warfarin therapy. Another study noted that bleeding complications were more frequent in patients on warfarin, however, still supported continuation of anticoagulation if the patient is stable with an INR <3.5 on an established regimen. Warfarin, clopidogrel, and aspirin were the most commonly studied AC/APs among the articles evaluated.

Conclusion: Our findings support the continuation of AC/AP therapy in most hand surgery patients. The risk of thromboembolic events associated with interrupting anticoagulation outweigh the potential for surgical bleeding requiring operative intervention. Further research should include larger patient cohorts and independent study of each type of hand operation to adequately power and generalize these conclusions.

References 1. Boer, Christa et al. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia, Volume 32, Issue 1, 88 - 120

2. Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. J Extra Corpor Technol. 2021 Jun;53(2):97-124.

3. Spyropoulos AC, Al-Badri A, Sherwood MW, Douketis JD. Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. J Thromb Haemost. 2016;14:875–85.

Introduction: Distal upper extremity nerve injuries (DUENIs) significantly impact patients' socioeconomic stability and overall well-being due to prolonged recovery periods and rehabilitation needs. Recent studies indicate that peripheral nerve injuries occur in 2-3% of over 3 million upper extremity trauma cases annually, with treatment costs reaching over $50,000 per case (1). These injuries can have a financial impact on patients, yet the personal financial burden of patients after DUENI surgery remains underexplored. Therefore, we assessed the personal financial burden and associated factors of DUENI surgery in digital versus non-digital nerve injuries. Methods: We conducted a cross-sectional survey of patients who underwent surgery for DUENI at two level-I trauma centers (2016-2023). Financial hardship was assessed using a validated financial composite burden score [0-6] and worry scale [1-5]. Primary analyses included financial burden severity, spending pattern changes, and risk factor identification, stratified by distal digital (zone 1: Fingertip to A1 pulley) versus more proximal nerve injuries (zone 2: A1 pulley to elbow crease) and injury severity. Multivariable Poisson regression and ordinal logistic regression models identified predictors of financial burden and worry, respectively. Results: A total of 133 patients were included, of whom 103 (77.4%) were male with a median age of 41.0 years (IQR: 33.0-61.0). Digital nerve injuries occurred in 104 patients (78.2%), while proximal nerve injuries were present in 29 patients (21.8%). Despite most patients (97.7%) being insured, 20.3% of those reported high financial worry, with proximal injuries showing greater discretionary spending reductions (44.8% vs 26.0%; p=0.050) compared to digital nerve injuries. Higher composite financial burden scores were associated with increased financial worry (OR=1.89; p<0.001). Prior debt was the strongest predictor of financial burden (β=0.99; p<0.001) and worry (OR=3.76; p<0.001), independent of injury complexity. Each additional surgery significantly increased financial worry for both the multi-trauma and single-nerve injuries (OR=2.37–3.34; p≤0.025). Proximal nerve injuries (OR=2.31; p=0.035) and male gender (OR=3.84; p=0.004) were also associated with increased financial worry. Younger age (β=-0.02/year; p=0.013) and surgeries involving multiple nerve repairs (β=0.18; p=0.038) were associated with financial burden. Conclusion: DUENIs can create substantial personal financial burdens despite high insurance coverage, with prior debt, surgical complexity, and proximal injuries emerging as key risk factors. Early risk-targeted counseling and surgical planning, particularly in the financially challenged younger manual laborers with complex proximal injuries, may mitigate financial toxicity. These findings may support tailored multidisciplinary care with early socioeconomic risk screening and social support to optimize resource allocation and interventions.

(1) Karsy M, Watkins R, Jensen MR, Guan J, Brock AA, Mahan MA. Trends and Cost Analysis of Upper Extremity Nerve Injury Using the National (Nationwide) Inpatient Sample. World Neurosurg. 2019;123:e488-e500. doi:10.1016/j.wneu.2018.11.192

Introduction Endoscopic Carpal Tunnel Syndrome Release (ECTSR) is a common surgical procedure with paucity of literature pertaining to anatomical landmarks, their distances and ratios to each other. We hypothesize that consistent anatomical ratios exist between key wrist landmarks used in ECTSR, and these ratios are symmetrical between left and right hands.

Methods Bilateral wrist and hand dissections were performed on 5 human cadavers at the Yale School of Medicine's anatomy laboratory. Three investigators independently measured distances between five key anatomical landmarks: the pisiform, flexor carpi radialis muscle tendon intersection with the wrist crease, hook of hamate, perpendicular intersection of the hook of hamate with the wrist crease, and median nerve. Three specific ratios were calculated: (1) the distance between pisiform and hamate-wrist crease intersection divided by pisiform to flexor carpi radialis distance, (2) distance between pisiform and median nerve divided by pisiform to flexor carpi radialis distance, and (3) the distance between hamate and its wrist intersection divided by pisiform to hamate-wrist intersection distance. Statistical analysis included calculation of means, 95% confidence intervals, and Mann-Whitney U tests to compare left versus right sides.

Results Statistical analysis revealed no significant differences between left and right hands for any of the three measured ratios. The first ratio showed a mean of 0.464 (95% CI = 0.223, 0.705) for left and 0.389 (95% CI = 0.244, 0.534) for right hands (p = 0.753). The second ratio demonstrated a mean of 0.681 (95% CI = 0.568, 0.794) for left and 0.652 (95% CI = 0.550, 0.754) for right hands (p = 0.675). The third ratio showed a mean of 1.7856 (95% CI = 0.3346, 3.2366) for left and 1.8748 (95% CI = 0.8718, 2.8778) for right hands (p = 0.69).

Discussion This study highlights existing consistent anatomical ratios between key wrist landmarks used in CTSR and these ratios demonstrate bilateral symmetry between left and right hands. The predictable nature of these relationships provides surgeons with reliable anatomical references for preoperative planning. These findings may improve surgical precision and safety during CTSR procedures by helping surgeons better anticipate the location of critical structures.

Background Brachial plexus birth injuries (BPBI) affect approximately 1 in 1,000 live births. While some cases recover with minimal deficits, others may require early microsurgical intervention, and ~30% experience long-term impairments, including limb length discrepancies and functional limitations. This study aimed to establish a rat pup model of BPBI to investigate the relationship between neonatal nerve injury and skeletal growth, specifically limb length inequality. Materials and Methods Using a dorsal approach under operative microscopy, a unilateral pan brachial plexus rupture was created in 3–9-day-old Sprague-Dawley rat pups by cauterizing the nerve root distal to the dorsal root ganglion. Pups were observed for 8 weeks post-surgery. Bilateral humeri were measured via microCT, and morphological changes were evaluated post-mortem. Results Ten rat pups underwent successful pan plexal injury creation. While two regained full function, the remaining pups exhibited functional deficits in the affected limb. MicroCT analysis revealed a mean limb length inequality of 1.8 mm in the operated humerus (p=0.009, 95% CI: 0.76, 2.84). Post-mortem evaluation confirmed a mean limb length inequality of 2.25 mm (p<0.001, 95% CI: 1.77, 2.73) and demonstrated significant morphological differences between the operated and unoperated humeri. Conclusions This rat pup BPBI model successfully produced morphologic changes and limb length inequality linked to disrupted innervation of the proximal humeral physis. Further analysis of the physis will elucidate the mechanisms driving altered skeletal growth following neonatal nerve injury

Purpose: Breast cancer treatment often involves a multidimensional approach involving systemic and locoregional therapies. Peripheral neuropathies have been reported as consequences for both these approaches, including specific studies on selective estrogen receptor modulators (SERM), aromatase inhibitors, platinum-based chemotherapies, and lymph node dissection. Carpal tunnel syndrome (CTS) is among the neuropathies identified, but there exists a paucity of research evaluating the management of CTS in this patient population and the effectiveness of carpal tunnel release (CTR) for symptomatic relief. This study seeks to address this knowledge gap.

Methods: A retrospective case-control chart review study was performed in the Cleveland Clinic's Electronic Medical Record. Study inclusion criteria: female patients over 18 years old with histories of CTS diagnosis and CTR treatment. The case group also required prior treatment of breast cancer not arising from metastasis. Chi-square, Welch's, and Fisher's tests were used as appropriate with Bonferroni corrections; significance was set at p<0.05. Summary statistics are reported as mean ± standard deviation.

Findings: Ninety-eight patients were included in the case (BRCA) group and 200 patients were included in the control. Despite efforts to match patients, BRCA patients were older than patients in the control group (63.1±11.9 vs. 51.1±12.8 years, respectively; p<0.01). The control group was more likely to have chronic kidney disease than the BRCA group (p<0.01), although other CTS-predisposing comorbidities had equal occurrences between groups. BRCA subjects were diagnosed with invasive ductal carcinoma (68.7%), ductal carcinoma in-situ (23.2%), invasive lobular carcinoma (9.1%), or lobular carcinoma in-situ (1.0%). Papillary or tubular carcinoma subtypes of ductal carcinoma were diagnosed in 2.0% and 1.0% of patients, respectively. The majority of BRCA patients were treated at stage 1 (78.9%), 18.3% were in stage 2 and 2.8% in stage 3. Surgical treatment of breast cancers involved breast-conserving surgery (67.0%), simple mastectomy (21.6%), modified radical mastectomy (7.2%), or other, non-radical mastectomy (4.1%). Adjunctive treatments included axillary surgery (38.8%), radiation (17.3%), chemotherapy (31.6%), SERM (57.1%), and immunotherapy (6.1%).

CTS diagnosis was accomplished using similar techniques between BRCA and control groups, with Tinel, Phalen, electromyography, and neuromuscular ultrasound tests being applied with comparable frequencies. Upon CTS diagnosis, the BRCA group was treated with conservative measures for shorter durations (p<0.01) than the control group, with significantly more BRCA patients' treatments concluding after six months. The BRCA group was also less likely to be treated with orthosis or steroid injections (p<0.05) without any difference in subjective improvement (p=0.725). Following CTR, both groups' DASH scores improvements were clinically significant (ΔDASHBRCA=40.01±19.29, ΔDASHcontrol=24.14±23.98 > 10). The BRCA group's relative DASH (p=0.034), BCTQ-F (p<0.01), and BCTQ-S (p<0.01) reductions following CTR were greater than those of the control group, although both groups demonstrated significant improvements in all examinations.

Conclusion: Breast cancer patients had greater reductions in CTS severity following CTR and similar responses to conservative therapy compared to other patients despite abbreviated conservative treatment durations. The observed accelerated transition from conservative to surgical treatment of CTS in patients following breast cancer is therefore effective and medically justified.

Title Enhancing Hand Vascular Assessment: The Role of Hyperspectral Imaging in Perfusion Monitoring

Abstract Accurate assessment and monitoring of tissue perfusion are critical in diagnosing and managing vascular diseases of the hand. Traditional methods, including clinical examinations and pulse oximetry, have limitations in detecting early or subtle perfusion deficits (1). Hyperspectral imaging (HSI) is a non-invasive, real-time technique that provides quantitative perfusion maps by measuring oxygen saturation, oxyhemoglobin, and deoxyhemoglobin levels. The purpose of this study is to evaluate the clinical utility of HSI in assessing perfusion in vascular conditions of the hand and discuss its emerging application in the field of hand surgery.

A single-center study was conducted from 2021 to 2025, involving 25 patients with various vascular and circulatory upper extremity conditions, each followed to present date. Perfusion images were obtained using the HyperView™ (HyperMed™, Memphis, TN) system before and after surgical or procedural interventions. Comparisons were made against the contralateral hand or standardized normal perfusion values from the previous iteration of the HyperView™ camera (OxyVu™-1). The effectiveness of HSI in diagnosing and monitoring perfusion changes was assessed through case analyses.

HSI effectively identified perfusion deficits, guided clinical decision-making, and monitored vascular improvements post-intervention. In several cases, HSI detected thrombosis, monitored post-procedural oxygen saturation changes, and provided immediate data that influenced urgent clinical decision-making. In a case of ulnar artery reconstruction, HSI demonstrated a 5% increase in tissue oxygen saturation postoperatively, ultimately correlating with successful wound healing. Another case involved a patient with Raynaud's, where pre- and post-treatment HSI assessments objectively demonstrated a 23% increase in perfusion following botulinum toxin injections. These results correlated with an improvement in the patient's clinical symptoms. Additionally, HSI influenced the decision for angiography and surgical intervention in a case of traumatic digital artery occlusion.

While HSI shows significant promise, limitations remain. Established baseline reference measurements for different anatomical regions are lacking, reducing interpretability. Factors such as melanin concentration, ambient temperature, and vasoactive substances can influence accuracy (2). Additionally, image quality may be compromised by improper exposure, motion artifacts, and variations in operator technique. Standardization of imaging protocols is necessary to enhance reliability.

HSI presents a novel, objective method for assessing tissue perfusion in vascular diseases of the hand and upper extremity, overcoming several limitations of traditional assessment techniques. This technology has the potential for integration into clinical workflows for real-time decision-making in hand surgery and vascular medicine. Furthermore, HSI has shown promise in assessing systemic vascular dysfunction, as demonstrated in studies of peripheral artery disease, and flap perfusion (3,4). Further research is required to establish standardized imaging protocols, validate clinical efficacy, and determine its broader applicability in disorders of the hand.

References

(1) Considine J. The reliability of clinical indicators of oxygenation: A literature review. Contemp Nurse. 2005;18(3):258-267. doi:10.5172/conu.18.3.258

(2) HyperMed Imaging, Inc. (2017). HyperView™ Product Overview (Part Number: 101-D077 Rev. B). Retrieved from https://hypermed.com/wp-content/uploads/101-D077Product-OverviewRev.-B1-1.pdf

(3) Sumpio BJ, Citoni G, Chin JA, Sumpio BE. Use of hyperspectral imaging to assess endothelial dysfunction in peripheral arterial disease. J Vasc Surg. 2016;64(4):1066-1073. doi:10.1016/j.jvs.2016.03.463

(4) Kohler LH, Köhler H, Kohler S, et al. Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study. BMC Surg. 2021;21(1):222. doi:10.1186/s12893-021-01232-0

Purpose Trapeziectomy and ligament reconstruction with tendon interposition (LRTI) improves pain and functionality in patients with carpometacarpal osteoarthritis (1). Post-operative had therapy has been shown to improve functional outcomes after LRTI (2, 3). We hypothesize that patients with lower functional scores in the immediate postoperative period engage in therapy for longer.

Materials and Methods Patients undergoing LRTI at a single academic institution between January 2015 and June 2024 were retrospectively reviewed. Postoperative, in-person therapy sessions with hand therapy were noted, along with clinic visits. The earliest and latest Patient-Reported Outcomes Measurement Information System (PROMIS) scores were recorded. Bivariate analysis was conducted to compare demographics and functional outcomes.

Results Overall, 1,235 patients underwent trapeziectomy for CMC osteoarthritis, with 845 (69.6%) females aged 65.1 [58.6,70.9] years. Therapy was attended by 1,039 (85.6%) patients for 4 [2,7] sessions over 7.3 [3.4,12.3] weeks. Among patients who did not attend therapy, 106 (60.6%) patients were referred.

Therapy Attendance Patients were stratified by whether they attended five or more sessions. Patients attending five or more sessions were less deprived, exhibiting lower national and state ADIs (both p<0.001); these patients also tended to be followed for shorter lengths of time by their surgeons (p<0.001). Patients who attended multiple sessions tended to have poorer initial PROMIS Physical Function (PF) and Upper Extremity Function (UEF) six weeks postoperatively (both p<0.05). Scores were equivocal at six weeks; but latest follow-up disclosed favorable Pain Interference (PI) in patients attending more therapy.

State Area of Deprivation State ADI was used to subdivide patients, and the top three and bottom three deciles were compared. Postoperative therapy did not vary between groups, but the number of session and duration were higher in patients who were less deprived (both p<0.05). Deprived patients had less favorable PI (p=0.046) at six weeks, and PI (p=0.033) and QuickDASH (p=0.028) at three months. Differences were not significant beyond three months.

Summary Patients undergoing procedural management of CMC osteoarthritis had high postoperative hand therapy attendance, with lower initial PF and UEF associated with attending multiple therapy sessions, leading to improvements in latest PI and UEF. Socioeconomic deprivation correlated with attrition from therapy, with more deprived groups having fewer therapy visits. Multidisciplinary care enhances postoperative outcomes, though both functional and socioeconomic factors influence therapy attendance.

References 1. Henstridge L. Development and implementation of a trapeziectomy rehabilitation protocol. Hand Therapy. 2017;22(2):64-72. 2. Hermann-Eriksen M, Nilsen T, Hove A, Eilertsen L, Haugen IK, Sexton J, et al. Comparison of 2 Postoperative Therapy Regimens After Trapeziectomy Due to Osteoarthritis: A Randomized, Controlled Trial. J Hand Surg Am. 2022;47(2):120-9 e4. 3. Stirton JB, Kagy KL, Mooney ML, Jain MK, Skie M. Early Mobilization After Basal Joint Arthroplasty: Clinical Results. Hand (N Y). 2023;18(2_suppl):81S-6S.

Background: Carpal Tunnel Syndrome (CTS) is the most common compressive neuropathy of the upper extremity, with diagnosis relying on history and physical examination. Effective patient-provider communication is essential for accurate diagnosis, treatment decisions, and outcomes (1); however, racial discordance can hinder communication, leading to mistrust, underutilization of treatment, and worsening disparities (2). Race and gender discordance among patients and providers influence decision-making and healthcare experiences (3). In contrast, racial concordance is associated with improved patient compliance and outcomes. In this qualitative study, we examined the perspectives on patient-provider communication among Black patients with CTS, with the primary goal of identifying barriers and facilitators to treatment when there is racial discordance among patient and providers.

Methods: We used interpretive description to understand the experiences of Black patients presenting to a single academic institution in the Midwest. Participants engaged in a one-on-one in-depth interview. Interviews were recorded, transcribed, and analyzed to identify key themes and strategies to improve patient provider communication.

Results: Our sample included 28 participants with CTS, 80% of whom were women. Three key themes emerged: Dismissiveness, Lack of Empathy, and Information Power. Participants described feeling ignored by providers, with one stating, "I told the doctor I was still having pain, and he just shrugged it off." (Participant 18). Some attributed this dismissiveness to racial bias, believing their symptoms would be taken more seriously if they were of a different race. Patients also reported a Lack of Empathy, particularly regarding surgical fears, as one shared, "I was really nervous, but the doctor acted like it wasn't a big deal and didn't acknowledge my fear." (Participant 15). Information Power played a crucial role in decision-making, with clear communication fostering trust and fragmented information leading to mistrust. One participant noted, "I only found out about one of the potential complications from Googling it later-it wasn't mentioned during the consultation." (Participant 8). Providers who were most transparent helped build confidence and trust, improving patient engagement in treatment.

Conclusion: Here we identified how aspects of patient-provider communication can serve as barriers or facilitators to care for Black patients with CTS, particularly in context of racial discordance. Provider dismissiveness and lack of empathy negatively impact patient-provider interactions. In contrast, transparency and the sharing of information power helps build confidence and trust in the provider. As we strive to improve racial disparities and promote equity in the treatment of CTS (and other conditions), it is critical that we continue to engage with patients and understand how their perspectives impact treatment decisions and overall outcomes.

References: 1. Forsey J, Ng S, Rowland P, Freeman R, Li C, Woods NN. The basic science of patient–physician communication: A critical scoping review. Acad Med. 2021;96(11S):S109-S118. 2. Shen MJ, Peterson EB, Costas-Muñiz R, et al. The effects of race and racial concordance on patient-physician communication: A systematic review of the literature. J Racial Ethn Health Disparities. 2018;5(1):117-140. doi:10.1007/s40615-017-0350-4 3. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583-589. doi:10.1001/jama.282.6.583

Introduction: Postoperative hand therapy is essential for restoring function and optimizing outcomes following flexor tendon repair[1]. This study evaluates the impact of insurance status and other predictors on therapy adherence at a single level one trauma and tertiary care center in the Deep South.

Methods: A retrospective cohort analysis was conducted on flexor tendon repair patients at a single institution (2014–2024). Patients requiring multiple procedures, < 18 years old, or receiving therapy elsewhere were excluded. Data on insurance status, social vulnerability, demographics, tobacco use, and therapy adherence were analyzed using univariate and multivariate regression.

Results: Among 300 cases, most patients were insured (79%, n=237). In univariate analysis, no theorized predictors were significantly associated with adherence: age (p=0.953), sex (p=0.596), race (p=0.437), insurance status (p=0.107), social vulnerability (p=0.946), and tobacco use (p=0.324). However, the number of canceled/no-show appointments (CNSA) (p<0.0001) and days to therapy initiation from surgical date (DTI) (p=0.020) were unexpectedly strong statistical predictors.

In multivariate regression, the model was initially nonsignificant (p=0.7614, R²=0.015) with only the theorized predictors, but became significant (p<0.0001, R²=0.26) when CNSA and DTI were included. Increased therapy visit cancellation events predicted more attended sessions overall (ß1=0.932, p<0.001), while delays in initiation of therapy visits reduced attendance adherence (ß2=-0.00267, p=0.0256).

Conclusion: Previously reported predictors of hand therapy adherence were not observed in this study, suggesting additional, unmeasured factors may influence post-operative attendance. This data highlights the benefit of encouraging continued engagement despite missed appointments and promoting early therapy initiation to obtain adherence success.

References: 1. Wong JKF, Peck F. Improving Results of Flexor Tendon Repair and Rehabilitation. Plastic and Reconstructive Surgery. 2014;134(6):913e-925e. doi:10.1097/prs.0000000000000749

Purpose Distal radius fractures (DRF) are common urgent hand consults that often require surgical fixation. Subsequent hand therapy referral is routine, but this heterogenous patient population often faces barriers to follow-up and therapy participation. We hypothesize that socioeconomically deprived patients are less likely to engage with therapy and exhibit poorer functional outcomes, based on Patient-Reported Outcomes Measurement Information System (PROMIS) and QuickDASH scores.

Materials and Methods Patients undergoing surgical management of DRFs at a single academic institution between January 2015 and June 2024 were retrospectively reviewed. Postoperative, in-person therapy sessions with physical or occupational therapy were noted, along with clinic visits. PROMIS scores were recorded at six weeks, three months, and six months. Bivariate analysis was conducted to compare demographics and functional outcomes.

Results Overall, 835 patients were included, with a mean age of 57.3 [34.9, 68.7]. Therapy was attended by 552 (66.1%) patients for 4 [2, 9] sessions over 7.5 [2.6, 14.2] weeks. Among patients who did not attend therapy, 108 (38.2%) patients were referred or advised to participate. Postoperative clinic visits were attended by 753 (90.2%) patients over 6 [1.9, 21.5] months.

Therapy Attendance Discussing or recommending therapy in the clinic significantly raised the odds of patient engagement (p<0.001, OR=6.82, 95% CI=4.40-10.69). Relative to private insurance, patients relying on Medicare (p<0.001, OR=0.29, 95% CI=0.16-0.54) or Workers' Compensation (p=0.021, OR=0.22, 95% CI=0.06-0.86) were less likely to attend. Patients with longitudinal participation had higher initial pain interference (PI, p=0.014), decreased upper extremity function (UEF, p=0.007), higher QuickDASH (p=0.042), and lower percent functional recovery (p<0.001). No differences were appreciated at three months. At the latest visit, these patients had lower QuickDASH scores (p=0.033).

Conclusions Therapy attendance in patients with DRFs was modulated by several factors, including insurance status, session attendance, and resource deprivation. More deprived patients had greater PI and subjective pain in the immediate postoperative period. Mental health likely has a role as patients with higher PI scores attended more therapy appointments. Patients who attended over five sessions had less favorable PI, UEF, and QuickDASH scores at their initial visit, but these differences disappeared with continued therapy involvement.

Purpose: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy worldwide, with menopause identified as a risk factor in previous literature. Despite this, limited data exist on outcomes for menopausal patients undergoing carpal tunnel release (CTR). This study seeks to compare complication rates between endoscopic CTR (ECTR) and open CTR (OCTR) in menopausal patients to provide plastic surgeons with more insight into this population. Methods: A retrospective cohort study was conducted using the TriNetX database, including 63,160 menopausal patients who underwent ECTR (n=17,135) or OCTR (n=46,025). Demographics, medical comorbidities, and complication rates were analyzed. A 1:1 propensity score matching was performed to calculate risk ratios and 95% confidence intervals for postoperative median nerve injury, tendon injury, complex regional pain syndrome, 6-week wound dehiscence, and 6-week wound infection. Results: After cohort matching, demographics and comorbidities were comparable between groups. Menopausal patients undergoing ECTR had a significantly lower relative risk of 6-week wound dehiscence (RR 0.471, 95% CI 0.296-0.751; p<0.001) and nerve injury (RR 0.389, 95% CI 0.21-0.721; p<0.001) compared to the OCTR cohort. No significant differences were observed in the risk of wound infection, tendon injury, or complex regional pain syndrome. Conclusions: Among menopausal patients undergoing CTR, ECTR was associated with significantly lower rates of wound dehiscence and nerve injury within 6 weeks post-surgery, reducing these risks by 52.9% and 61.1%, respectively. These findings suggest ECTR may result in improved outcomes for this patient population. Plastic surgeons should consider menopause as an underlying factor or comorbidity when evaluating and managing CTS.

Abstract: Hypothesis: SETS is an efficient method to restore hand intrinsic function in peripheral ulnar nerve injuries. Background: Supercharge end-to-side (SETS) anterior interosseous nerve transfer is a surgical technique employed to enhance nerve regeneration and functional outcomes in cases of peripheral nerve injuries. This innovative procedure involves connecting the injured nerve to a donor nerve in an end-to-side fashion, thereby promoting nerve regeneration. Material and Methods: A retrospective study of patients who underwent SETS anterior interosseous-to-ulnar nerve transfer for compression ulnar neuropathy from 2004 to 2022 was performed. Mean follow-up time was 23 months. The primary outcomes were return of ulnar intrinsic function by assessing the Medical Research Council grade of the first dorsal interosseous muscle, ability to cross the index finger, and improvement of clawing. The secondary outcome measures were grip strength, oppositional pinch strength, and key pinch strength. Postoperative patient reported outcomes were assessed with QDASH and ABILHAND survey scores. Categorical variables and continuous variables were compared with Fischer's exact and paired- t tests, respectively. Results: Thirty-one anterior interosseous-to-ulnar nerve transfers met inclusion criteria. The mean British Medical Research Council (MRC) values of the first dorsal interosseous (FDI) muscle improved compared to preoperative values (1.8 vs. 3.7, p =.001). Ninety percent of the patients achieved a satisfactory recovery (MRC ≥ 3). Grip strength (61 vs. 69, p =.03) and key pinch strength (49 vs. 68, p =.003) improved postoperatively. Postoperative average QDASH score and ABILHAND scores were 36 (25) and 66 (18), respectively. The first documented intrinsic hand function was as early as within 1 month (range, 1–20), with a mean of 3.6 months. Time-to-surgery had a significant impact on intrinsic muscle strength recovery. Patients treated within 12 months of symptom onset had a higher MRC grade compared to those treated after this period (4.1 vs. 3.3, p =.02). More than 60 percent of the patients noted partial or complete resolution of clawing and muscle wasting. Compound muscle action potential (CMAP) and sensory nerve action potentials (SNAP) of the abductor digiti minimi (ADM) increased from baseline; however, this did not achieve significance.

Conclusion: SETS transfer restores ulnar intrinsic function in 90% of patients with compression-type injuries. Initial recovery could be expected as early as 1 month (mean, 3.6 months.); however, to achieve a satisfactory recovery (MRC ≥ 3), AIN transfer should be conducted within 12 months of symptom onset.

Purpose Citation analysis is a crucial bibliometric tool that quantifies the impact and influence of published articles within their respective fields. This study presents the first comprehensive literature survey in the rapidly evolving field of Regenerative Peripheral Nerve Interface (RPNI) surgery and Targeted Muscle Reinnervation (TMR). With 185,000 amputations occurring annually in the US alone, these innovative techniques address critical challenges in post-amputation pain management and prosthesis control. Our bibliometric analysis aims to quantify global contributions and assess the impact of these novel surgical approaches on current practice, providing valuable insights for future research direction. Methods The 100 most-cited articles relating to RPNI surgery and TMR published between January 1, 2000, and December 1, 2024, were extracted from Web of Science (WOS) database in December 2024. The database was systematically searched using a comprehensive set of keywords related to RPNI, TMR, and associated concepts. Inclusion criteria focused on relevance to pain management for neuroma and phantom limb pain, or prosthetic control, in peer-reviewed journals. Title, publication year, total citations, authorship, country, institution, journal, research area, and common keywords were recorded for bibliometric analysis. Bibliometric network visualizations were created using VOSviewer software to illustrate relationships. The methodology ensured a thorough and reproducible analysis of the most influential literature in the field over the past 24 years. Results The bibliometric analysis of publications on RPNI surgery and TMR revealed 4,807 articles with 144,742 total citations. The top 100 most-cited publications accounted for 13,709 citations, with the most cited article receiving 752 citations. Todd A. Kuiken emerged as the most prolific author with 28 publications in the top 100. Northwestern University led institutional contributions with 40 publications and 6,707 citations. The year 2014 saw the highest number of publications (15). IEEE Transactions of Neural Systems and Rehabilitation Engineering was the most active journal with 11 publications and 1,411 citations. Engineering was the top research area with 36 citations. The United States had the highest number of contributions to the top 100 articles with 73 publications and 9,988 citations. Key research themes identified through keyword analysis included pattern recognition, myoelectric control, prosthesis, neuroma, and phantom limb pain. Conclusions This bibliometric analysis reveals the significant impact and growing relevance of RPNI and TMR research in plastic surgery and related fields. By identifying key contributors, research trends, and areas of focus, this study provides a valuable resource for researchers and clinicians working to improve outcomes for individuals with limb loss. The analysis underscores the need for continued innovation and collaboration in this rapidly advancing field, highlighting opportunities for future research and development in areas such as neural engineering and sensory feedback systems.